DiDiMap. Diet Diary and Consumption Control for Monitoring Bowel Dysfunctions and low-FODMAP Diet App

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Department of Computer Science

DiDiMap

Diet Diary and Consumption Control for Monitoring Bowel Dysfunctions and low-FODMAP Diet App

—

Tobias Robin Borgen Olsen

INF-3981 Master thesis in informatics - June 2019

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Abstract

The purpose of this project was to design and implement a mobile application for people with bowel dysfunctions, intolerances, and food allergies. The application was expected to provide all needed functionality for the target groups day to day challenges.

Irritable bowel syndrome, intolerances, and food allergies affect a significant portion of the population. On a world basis, 15% of the population are affected by IBS alone 1. Although intolerances and food allergies are handled better than before in terms of adaptation from restaurants, food producers, and grocery stores, there’s still a long way to go. Food producers and caterers must, by law, inform consumers of whether their products contain certain common allergens.

If a person has an allergy or intolerance outside the standard, there’s little information to get.

A systematic review and an app review mapping existing knowledge and implementations for similar apps were conducted. A mobile application was implemented for a low-FODMAP (Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) use case based on the conducted reviews features and shortcomings. The app contains features such as optical character recognition to identify potential trigger foods, barcode scanning of food products to retrieve nutritional and intolerance information, and a log to track meals, events during the day, and symptoms. The application also includes a communication platform for connecting and communicating with peers, which can later be expanded into discussion and motivation groups. Unlike other similar applications in the market, the app provides, in addition to peer communication, all needed functionality in a single platform, which enables utilization of log data for consumption control.

We conducted a trial of the application with 65 users who were currently following a low-FODMAP diet. Of these 8 people responded to an anonymous survey asking users to rank the system’s usability on a scale, and to answer a few application-specific questions. Feedback from user testing indicated a

1.https://www.monashfodmap.com/

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great interest in the app. Through the survey the app gained a system usability score of 85/100, and 75% thought the app would greatly simplify the process of following the low-FODMAP diet.

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Preface

In 2017, I was referred to the web page of Helse Bergen on their section on FODMAPs after a period of declining health. After taking a quick look at their site, the low-FODMAP diet was deemed too absurdly complex even to attempt.

After some time, and with limited options, the diet was tested all the same, and some factors became apparent. It was very complicated and comprehensive, challenging to follow, and the information that existed was difficult to navigate.

To begin with, grocery shopping for low-FODMAP items could easily take an hour and a half. Since I knew nothing on the matter, each ingredient on every single item I wanted to buy had to be cross-checked against some pdf, Google or app, often after I had translated the ingredient into English. After manually checking thousands of ingredients There was no doubt, the process should have been simpler. Most people following the low-FODMAP diet has some sort of unexplainable bowel dysfunction, and are often neatly put into the irritable bowel syndrome category. Irritable bowel syndrome is estimated to affect 15%

of the world’s population, which leaves the question: Why hasn’t someone simplified the low-FODMAP process through the use of mobile technology to a satisfying degree yet? Once I had the opportunity to invest time and effort into attempting to solve the issue, there was no doubt in my mind that I needed to step up and do my part.

This project would not be possible without the help and guidance from my supervisors Gunnar Hartvigsen, Ashenafi Zebene Woldaregay, and Eirik Årsand.

Especially thanks to Gunnar, who believed in my project and gave me the possibility to develop a tool which I strongly believe can help myself and others overcome some of the challenges related to bowel dysfunctions. My supervisors’

input and knowledge have been of tremendous help. I want to thank the medical informatics and telemedicine group for the great feedback on the mobile app. I also want to thank my co-students at my office Marius Wiik, Vebjørn Haugland, Sverre Coucheron and Valter Berg for the input, discussions, and laughs. Thanks to Pontus Aurdal for helping me learn frontend development. Thanks to Jørgen Lund for reviewing my thesis. Thanks to Petter Tunstad for the cooperation throughout the study. Thanks to both Petter and Håkon Wallan for great climbing sessions and reducing my stress levels. Thanks to Landsforeningen mot fordøyelsessykdommer for their support and help with spreading the news

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of the app to the community, thereby greatly helping the testing process.

Thanks to Matinfo.no for providing product data for the app. Special thanks to Monash University for being the world leader on FODMAPs and providing the public with valuable FODMAP information. Thanks to Helse Bergen and Frisk forlag for translating FODMAP values to Norwegian and creating searchable Norwegian lists and providing other useful information on bowel dysfunctions and intolerances. I want to thank all participants of the test phase of the project, especially thanks to those who answered the questionnaire. Lastly, I need to thank my family and friends for their support over the years.

Tromsø - 01.06.2019

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List of Figures

1.1 Implemented application . . . 4

2.1 Prisma flow chart . . . 10

2.2 M. W. Wong et al. user interface . . . 11

2.3 Albert Parra Pozo et al. user interface . . . 12

2.4 J. Ahn et al. user interface. . . 13

2.5 S. Konrad et al. user interface . . . 14

2.6 R. Karkar et al. user interface . . . 15

2.7 M. de Jong et al. user interface . . . 17

2.8 Screenshots from the app FODMAP by Monash . . . 23

2.9 Screenshots from the app FODMAP helper . . . 25

2.10 Screenshots from the app Low FODMAP diet A-Z Food list for IBS sufferers . . . 27

2.11 Screenshots from the app My Food Intolerance List . . . 29

2.12 Screenshots from the app Mr symptoms Food Diary Symptom Tracker . . . 31

3.1 LMF first post . . . 36

3.2 LMF second post . . . 37

3.3 Google play store . . . 38

3.4 Home page . . . 39

4.1 Time line of example of use . . . 44

5.1 Old vs new color scheme . . . 50

5.2 Log categories, overview and adding entries . . . 52

5.3 Log notification . . . 53

5.4 Forum . . . 54

5.5 Input text . . . 56

5.6 Scan ingredient procedure. . . 56

5.7 Barcode scan procedure . . . 58

6.1 System architecture . . . 60

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8.1 SUS score grading . . . 76

A.1 Introduction . . . 94

A.2 Overview . . . 95

A.3 Multiple variants. . . 96

A.4 Adding non-analyzed food. . . 97

A.5 Finding non-analyzed food . . . 98

A.6 Utilizing the camera for the OCR feature . . . 99

A.7 Log . . . 100

A.8 What can be logged? . . . 101

A.9 How to log . . . 102

A.10 Why log? . . . 103

A.11 How to utilize barcode scanner . . . 104

A.12 Adding a product . . . 105

A.13 Forum . . . 106

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List of Tables

2.1 Systematic review . . . 18 2.2 App review . . . 20

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1

Introduction

1.1 Motivation

Bowel dysfunctions and allergies are on the rise. These problems are affecting more people than ever before and causing more challenges than earlier for the people affected as well as their family and friends. Although a significant amount of people are affected by bowel dysfunctions and allergies, there is little data on how and why a person gets these problems, and there are no cures available. For this group of people, controlling food intake by staying clear of trigger foods are one of the few remedies capable of reducing their symptoms. When it comes to bowel dysfunctions, reducing stress can also significantly lessen the symptoms. The number of trigger foods a person with a bowel dysfunction can gain symptoms from is often too large to keep track of manually, therefore, technical aid such as mobile-apps or Google is often used to aid in this endeavor.

1.2 Problem statement

Keeping track of food intake and intolerances as well as the resulting symptoms is difficult, especially when following complex medical diets such as the low- FODMAP diet. This challenge is mainly felt by the individuals suffering from intolerances or digestive disorders, but controlling intake is a challenge also met by family, friends, and caterers. Although there are information and lists

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available for cross-checking meals against a diet, it’s a slow and manual process which requires experience, and is unsuitable for persons who have newly developed intolerances as well as others with little knowledge such as friends, family, and caterers. There exist some excellent apps for logging, but having a standalone log-app increase the effort needed from the user compared to having an all-in-one solution. Having one app for logging and one for controlling intake also means that the data on symptoms from earlier consumption cannot be used in the application when controlling intake. Analyzing ingredients for values such as FODMAPs is a slow process conducted at few laboratories worldwide. This creates a clear limitation on the amount of analysis done.

Sharing experience and collaborating on exploring new ingredients between users would further increase the knowledge, and simplify the process for the target group.

We express these issues in four questions which we will set out to answer.

Research problem 1: Which characteristics does a mobile application for simplifying the daily life of people with bowel dysfunctions, intolerances or food allergies need?

Research problem 2: Which work has been done in the field, and which apps are available in the market?

Research problem 3: Which functionality is needed to help the target group with their daily challenges?

Research problem 4: How is the application described and implemented in this thesis received by the target group?

1.2.1 Assumptions

For the application to provide the best experience, we assume users have a basic understanding of their diagnosis, intolerance, or allergy.

1.3 Nature and scope of problem

The scope of the project is limited to a mobile application which provides the user with the functionality needed on a daily basis, and a backend supporting the mobile application. The project does not attempt to build a platform for linking such apps to any health provider.

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1.4 Method

The app was created from an iterative approach where first, a systematic and app review was conducted to establish needed and expected functionality. A long-term follower of the low-FODMAP diet with IBS was consulted concerning which functionality was wanted, which was not available in the Norwegian market. The idea was communicated to the Norwegian national federation against bowel diseases which were positive to the app. Once the idea of functionality and design was in place, and a rough implementation was created, the federation spread the idea to their members through a Facebook post.

Before the official testing phase, a pilot test was conducted within the medical informatics and telemedicine research group at UIT as well as with co-students, friends, and family. The pilot test revealed small bugs and inconsistencies which were corrected before the user test. Through the Facebook post ca. 100 testers were recruited who received the app once the testing period started, of which 65 installed it. Once the testing stage was completed, the testers were asked to fill out an anonymous questionnaire containing the system usability scale [1] as well as some app-specific questions concerning functionality. The questionnaire results were analyzed manually and through the scoring system of the system usability score model.

1.5 Signiﬁcance and contributions

The project has reviewed studies and apps representing the state of the art within the field. The reviews has given insight into both available and proposed applications, as well as their features and shortcomings. Combined with consulting the target group, needed functionality as well as the characteristics for a mobile application covering the needs of the intended users has been mapped. The proposed application has been implemented and distributed for a pilot test and a user test. Through a questionnaire distributed to the test users, the app has received a system usability score and general feedback. The application, displayed in figure 1.1 on the following page was well received by the testers.

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Figure 1.1:Implemented application

1.6 Organization

The thesis is divided into 11 parts. Chapter 1 contains the introduction. Chapter 2 examines the theoretical background for the project, including a systematic review and an app review. This section lays the groundwork for the project.

Chapter 3 examines the methods used in the development process. Chapter 4 explain the requirements of the project, which has been based on the theoretical background as well as requests and needs received from the target group. In chapter 5, we look at the design of the application, followed by the implementation in chapter 6. Chapter 7 display the results of the user test.

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In chapter 8, we discuss and evaluate the app and the project as a whole. In chapter 9, we take a look at future work and the path going forward. In chapter 10, We wrap things up with a conclusion. Lastly, an appendix is presented, including user documentation for the app.

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2

Theoretical framework

2.1 Medical background

2.1.1 IBS and IBD

Irritable bowel syndrome is an umbrella term for unexplainable bowel dysfunctions. Common symptoms from IBS are constipation, diarrhea, abdominal pain and bloating. From what can be seen with today’s methods of diagnostics and technology, there is nothing physically wrong with a person with IBS, although there is no doubt that there exists a problem which causes physical symptoms.

IBS might be rooted in psychology, might be a physical issue, but is most likely a combination of both. There is no doubt that both food intake and psychological factors play a part in the symptoms and general well being of a person with IBS.

IBS affects a person’s ability to digest food, making foods which are already difficult to digest for a fully functional bowel especially problematic. There is no cure available for IBS patients, but the medical low-FODMAP diet has proven effective to reduce symptoms for 3/4 of the patients1. Reducing stress, anxiety, depression, and generally better the mental health of the patients has also been proved effective 2.

1.https://www.monashfodmap.com/ibs-central/i-have-ibs/starting- the-low-fodmap-diet/

2.https://helse-bergen.no/avdelinger/medisinsk-avdeling/

gastroenterologisk-seksjon/nasjonal-kompetansetjeneste-for- funksjonelle-mage-tarmsykdommer/irritabel-tarm-syndrom-ibs

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Inflammatory bowel disease is an umbrella term for diseases involving chronic inflammation of the patients’ digestive tract. IBD includes the diseases Chrons and Ulcerative Colitis. IBD often includes symptoms such as diarrhea, abdominal pain, fatigue, and weight loss, and can cause life-threatening complications.

Treatment of IBD includes medication, surgery, and dietary changes.

2.1.2 FODMAP

To ease the symptoms of bowel dysfunctions such as IBS, the low-FODMAP diet has been created at Monash University 3. Fermentable oligosaccharides disaccharides and polyols (FODMAP) are hard to digest and are not properly absorbed in the gut, making them a common source of problems and discomfort for individuals with IBS. Decreasing the amount of FODMAPs in the diet has proved to reduce symptoms for a significant amount of IBS sufferers. FODMAPs are a collection of carbohydrates and are therefore included in thousands of food items. The large amount of food containing a high amount of FODMAPs makes keeping track of which food to avoid difficult.

2.2 Technical background

2.2.1 Optical character recognition

Optical character recognition consists of recognizing text or objects in images and is a field within pattern recognition and artificial intelligence. For an OCR engine to be effective, it has to utilize machine learning to be trained with images of known content. To additionally better the accuracy, advanced pre-processing of the images can be done to simplify the recognition process itself. This could include, but is not limited to changing the image’s color and contrast, or crop the image. OCR engines are tuned explicitly for the use case, and a programmer must as such know the use case well for it to provide the best result.

2.2.2 JSON Web Tokens

JSON web Tokens or JWT for short is a URL-safe compact credential system used to authenticate users. In systems using JWTs, a JWT is typically generated on user registration and refreshed periodically for security reasons. If the JWT falls into the hands of anyone else than the user, they will have access to the

3.https://www.monashfodmap.com/about-fodmap-and-ibs/

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users account until the JWT is refreshed. The token is saved at the client, and sent with requests to authenticate the user at the server. For token based authentication, Jason Web Tokens is the industry standard. ⁴

2.3 State of the art

2.3.1 Systematic review

The database search was conducted on Scopus ⁵, which is the largest database on abstracts and citations of peer-reviewed literature. The following search query was used:

TITLE-ABS-KEY((((meal OR symptom) AND (logging OR tracking) AND (bowel OR food intolerance OR IBS OR food allergies OR Crohn’s OR ulcerative colitis OR celiac disease)) OR IBS OR fodmap OR (Intolerances OR (food AND allergies)) OR (bowel OR food intolerance OR IBS OR allergies OR Crohn’s OR ulcerative colitis OR celiac disease))AND (app OR mobile application)) AND ( LIMIT-TO ( LANGUAGE,"English" ))

The search yielded 113 papers, of which 15 has been included in this thesis.

Papers excluded were either within the wrong scientific field, or too broad/narrow to be applicable. Figure 2.1 on the next page displays the process through a Prisma [2] flow chart.

4.https://jwt.io/introduction/

5.https://www.scopus.com/

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Records identified through database searching (Scopus)

(n = 113)

Records screened

(n = 113) Records excluded

(n = 89)

assessed for eligibility (n = 24 )

Studies included in qualitative synthesis

(n = 15)

Studies included in quantitative synthesis

(meta-analysis) (n = 15)

Full-text articles excluded, with reasons

(n = 9) (Papers not relevant due to

too broad/narrow focus)

IdentificationScreeningEligibilityIncluded

Figure 2.1:A flow chart of the systematic review, based on the process described in [2]

The papers included in the quantitative synthesis are described below. Key findings for each paper are also displayed in table 2.1 on page 18.

M. W. Wong et al. [3] presents a prototpe application which provides OCR ingredient scan and barcode ingredient scan which provides information on

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trigger foods based on an intolerance database. The prototypes user interface is presented in figure 2.2.

Figure 2.2:M. W. Wong et al. [3] user interface, Figure 2b-e

Pros:

• Has OCR ingredient and barcode scan.

Cons:

• Is not a complete platform for people with bowel dysfunctions.

• Does not contain log or log analysis.

• Has no link between earlier experience and current consumption.

• Does not connect peers.

• Has no FODMAP overview.

Albert Parra Pozo et al. [4] propose and create a prototype system utilizing optical character recognition to translate foreign menu items/ingredients and cross-check the ingredients against a database containing nutritional information and allergens/intolerances. The interface of the prototype is displayed in figure 2.3 on the following page.

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Figure 2.3:Albert Parra Pozo et al.[4] user interface, Figure 5a-d

Pros:

• OCR ingredient scanner usable for many languages.

Cons:

• Has no barcode scanner.

K. Henricksen and S. Viller [5] present a paper covering diet diaries for families with children who have food-allergies of intolerances. In the paper, they presented a simple food log app and conducted a test concerning how often the app was used compared to a paper journal. The app was used less than the paper journal. The paper proposed increasing the likelihood of logging through gamification, reminders, and simplifying the logging process through saving earlier entries for quicker adding of entries.

Z. Mujagic et al. [6] presents a paper which covers the accuracy of logging between logging at the end of the day (recall method) vs. logging at multiple random moments during the day (experience sampling method). Logging through the recall method provided higher numbers on discomfort than logging through the Experience Sampling Method.

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J. Ahn et al. [7] suggests and prototypes an augmented reality mobile-app displaying information whether a product in a store aisle is healthy/unhealthy and contain food allergens. Figure 2.4 displays the apps interface.

Figure 2.4:J. Ahn et al. [7] user interface, Figure 8ab

Pros:

• Finds products through pointing the camera.

• Checks the products for trigger foods.

Cons:

• Must map each store for product placement.

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S. Konrad et al. [8] propose a machine learning based diet-log app which can predict the health of a person based on logged meals. The app is designed to give personalized information of which food a user should stay clear of.

Figure 2.5 displays the apps interface.

Figure 2.5:S. Konrad et al. [8] user interface, Figure 3

Pros:

• Has advanced log and log analysis.

• Predicts effects of food the user wants to consume.

Cons:

• Is a pure logging app and is missing needed features.

R. Karkar et al. [9] explains a framework which simplifies the process of experimenting with trigger foods. The framework tells the person, based on his

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goal, what to eat or drink (or not) until the framework has figured out whether this food/drink cause triggers based on symptom feedback. The applications interface is presented in figure 2.6.

Figure 2.6:R. Karkar et al. [9] user interface, Figure 4

Pros:

• Simplifies experimenting with potential trigger foods.

Cons:

W. K. Van Deen et al. [10] propose a set of questions and scoring system for

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monitoring of the health of a patient who has ulcerative colitis or Crohn’s disease. The questions and scoring system yielded accurate results for both UC and Crohn’s but need tailoring for the characteristics of each disease.

D. V. Ankersen, P. Weimers, and J. Burisch [11] review existing tools for IB- S/IBD patients and which features these have compared to requested features from sufferers. Reintroduction stage for FODMAPs and direct contact with medical personnel are often missing from the apps, which leaves room for improvement.

D. Con et al. [12] cover information gathering from IBD patients concerning the willingness to use e-health solutions for self-management. The majority of patients were willing to use such solutions.

P. Bossuyt et al. [13] takes a critical look at the challenges in using e-health for IBD patients, and points to four areas that should be investigated further before big implementations are started. More clinical trials to figure out effectiveness, multi-model monitoring tools, understanding patients resistance, and a wider digital framework connecting different e-health tools. The paper concludes that the field is not yet ready for widespread implementation.

M. Kelso and L. A. Feagins [14] have reviewed available apps for IBD patients.

Their paper concludes that medical personnel needs to be at the forefront of the development of such apps, and that effectiveness studies are needed. It also points out that future studies are needed to create validated tools to better patient compliance and decrease the cost of care.

B. C. Helsel et at. [15] reviews the effectiveness of telemedicine and health technology in the management of digestive diseases. Their paper concludes that telemedicine and mobile health technology may be effective to improve the quality of life and management of the disease for the users. Studies reviewed showed promising results.

W. Szeto et al. [16] conducted a study which included 109 adolescent IBD patients with a mean age of 18. 17% looked up information about IBD "always"

or "often" on a daily basis. 47% turned to medical websites for information, 16% connected with other IBD patients. Preferred method of communication with a health provider was by e-mail. 2% used mobile apps for monitoring of symptoms. 9% used apps for medication reminders. There was professed interest in the use of such apps.

M. de Jong et al. [17] propose and develop an IBD app for everyday use for all IBD patients. The app provides monthly monitoring(contains questions regarding disease activity, medication use, extraintestinal manifestations,

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medication adherence, treatment satisfaction, side effects, work productivity, nutritional status, fatigue, physical exercise, stress, life-events, anxiety and depression, social support and self-management skills.), personal care plan based on monitoring to better self-management, e-learning modules and communication(administration page for health care provider which gives overview over patients and potential red flags based on monitoring, as well as direct messaging). Lastly, the app includes an outpatient visit module which provides a questionnaire concerning variables necessary for the consultation, making it as effective as possible. Questions included are about disease activity, extraintestinal manifestation, smoking, work productivity, intimacy and sexuality, anxiety and depression, medication adherence, social support, and fatigue. The application showed high compliance score with 100% of the users filling in the monthly monitoring questionnaire. The patients scored the app 7.8 out of 10, while the providers scored 8 out of 10. Figure 2.7 displays the apps user interface.

Figure 2.7:M. de Jong et al. [17] user interface, Figure 3

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Pros:

• Provides extensive logging/monitoring for IBD patients.

• Provides IBD information.

• Provides direct connection with health provider.

• Provides personal care plan.

Cons:

• Monitoring is too extensive for IBS/general intolerances.

• Provides no simple help for controlling intake by for example OCR or barcode scanning.

Table 2.1:Systematic review

Paper Findings

A Mobile Adviser of Healthy Eating by Read- ing Ingredient Labels

Prototype of ingredient scanner and barcode scanner which returns nutritient and intolerance/allergy information

A Hand-Held Multimedia Translation and Interpretation System with Application to Diet Management

Protoype of OCR app which translates tex- t/ingredients and returns nutritional and intolerance/allergy information

Design of Software to Support Families with Food-Allergic and Food-Intolerant Children

Usage of simple log app was used less than paper journal for families with intolerant children. Proposed gamification, reminders and simplifying the log to increase use

The Experience Sampling Method - a new digital tool for momentary symptom assess- ment in IBS: an exploratory study

Logging at multiple random moments during the day is more accurate than logging at the end of the day

Supporting Healthy Grocery Shopping via Mobile Augmented Reality

Prototype of augmented reality app for finding healthy products within the users diet through the use of the camera

PancreApp: An Innovative Approach to Com- putational Individualization of Nutritional Therapy in Chronic Gastrointestinal Disor- ders

Machine learning based diet-log app which predicts users health based on logged meals

A framework for self-experimentation in personalized health

Framework which simplifies experimenting with trigger foods

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Development and Validation of an Inflam- matory Bowel Diseases Monitoring Index for Use With Mobile Health Technologies

Creates set of questions and scoring system for monitoring health of UC and Chrohn’s patients

Whats ‘App-ening’: the help of new technologies in nutrition in digestive diseases

Reintroduction stage for FODMAPs and direct contact with health provider is often missing from apps

eHealth for inflammatory bowel disease self- management – the patient perspective

Major majority of IBD patients are willing to use e-health solutions

E-health in inflammatory bowel diseases:

More challenges than opportunities?

For IBD e-health solutions, more investi- gation is needed concerning effectiveness, multi-model monitoring tools, patient resistance and digital framework connecting e-health tools. Field not yet ready for widespread implementation

Can Smartphones Help Deliver Smarter Care for Patients With Inflammatory Bowel Dis- ease?

Medical personnel must be at forefront of app development. Effectiveness studies are needed. Validated tools to better compliance and decrease care cost needed

Telemedicine and Mobile Health Technology Are Effective in the Management of Digestive Diseases: A Systematic Review

Telemedicine and mobile technology may be effective in improving quality of life for people with digestive diseases

Use of Social Media for Health-Related Tasks by Adolescents With Inflammatory Bowel Disease: A Step in the Pathway of Transition

Questionaire 109 IBD patients, mean age 18.

17% looked up IBD info "always" or "often" every day. 47% used medical websites, 16% connected with other patients. E-mail was preferred method of communication. 2% used logging apps, 9% used medication reminder apps. Professed interest in such apps Development and Feasibility Study of a

Telemedicine Tool for All Patients with IBD:

MyIBDcoach

App which provides monthly monitoring re- ports, personal care plan, e-learning, communication with health provider. 100% of users filled out the monthly monitoring questionnaire.

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2.3.2 App review

Google play store and Apple store were searched for apps concerning FODMAP and IBS. The app review consists of the top resulting apps, in addition to an app found while searching for apps doing optical character recognition for allergies.

The apps reviewed and their key features are displayed in table 2.2.

Table 2.2:App review

App Producer Features

FODMAP Monash FODMAP overview, personal-

ization, log, FODMAP reintroduction, recipes

low FODMAP av Molyssa Molyssa FODMAP

overview(Norwegian), product overview(norwegian), recipes, information, shopping list

FODMAP FM FODMAP overview, barcode

scanner (FODMAP info), personalization, log

Noba Iterate AS FODMAP

overview(Norwegian), product overview(norwegian), barcode scanner (FODMAP info), add products and esti- mate FODMAPs manually Low FODMAP diet A-Z Food

list for IBS sufferers

Temeraire 1978 Ltd FODMAP overview, personalization

Fodmap Helper Appstronaut Studios FODMAP overview, log, log analysis, share food experience with community (Ana- lyzed foods), FODMAP reintroduction

Low FODMAP Diet Axcore FODMAP information

Low Fodmap meal recipes Andromo FODMAP information

The low-Fodmap’s Diet plan Not found FODMAP information

Belly Balance Belly Balance FODMAP overview, barcode

scanner(FODMAP info), log, log analysis

Low-Fodmap diet plan for be- ginner’s guide

AngelicMiho FODMAP information

Food Intolerance Baliza GmbH Trigger food overview, per-

sonalization

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Fodmap Friendly FODMAP Friendly FODMAP overview, product overview

FODMAP Food Guide In Ident FODMAP product overview

FODMAP deutsche liste Not found FODMAP overview

FODMAP SWAPP Kerith Duncanson Suggests FODMAP friendly

foods to replace wanted food

Low Fodmap Diet GSMFlasher FODMAP information

My low Fodmap Life Not found FODMAP recipes

Low Fodmap Diet RBJmobile app FODMAP information

FODMAP all in one FODMAP All in One Team FODMAP overview, personalization, add tested ingredients to private list

Low Fodmap Diet Rnamobile FODMAP information

500 Low-Fodmap recipes Trellisys.net FODMAP recipes

Low-Fodmap diet Sean Colombo FODMAP overview

FODMAP Bspham FODMAP overview, product

overview, barcode scanner (FODMAP info)

My Food Intolerance List cr3ative.info, Steffen Mauser FODMAP overview, personalization, add tested ingredients to private list

FODMAP finder Peter Schofield Overview over FODMAP in-

formation Low Fodmap diet guide for

beginners

Soufien Game FODMAP information

IBS Diet Match with low- Fodmap diet

Informdiets Ltd FODMAP information,

recipes Mr symptoms Food Diary &

Symptom Tracker

SkyGazer Labs Ltd Log, log analysis

Low-fodmap recipes Membermedia FODMAP recipes

Casa De Sante MBODY360 FODMAP recipes, shopping

list, log

FODMAPer Joopkins FODMAP overview

Food and symptoms diary lite

nmi-Portal / panthera.cc Log Allergy Checker - Food Al-

lergy Tracker Allergy App

Sportistic Scan text for trigger foods, personalization

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The most downloaded apps are FODMAP by Monash 100 000+, FODMAP Helper 50 000+, Low FODMAP diet A-Z Food list for IBS sufferers 50 000+, My Food Intolerance List 100 000+, and Mr symptoms Food Diary and Symptom Tracker 100 000+.

FODMAP by Monash

The FODMAP app by Monash is the most established FODMAP app in the market.

Since Monash University is the world leader on FODMAPS, the app provides the newest FODMAP information available. It also provides personalization of FODMAP intolerances, a log, recipes, and a feature for FODMAP reintroduction.

Screenshots from the app are displayed in figure 2.8 on the facing page.

Pros:

• Most recent information.

• Personalization, log, recipes, reintroduction stage.

Cons:

• Has no OCR feature, all lookups must be done manually.

• Has no barcode scanning.

• Does not display earlier logged experience when looking up food (does allow for notes on food).

• Has no in-app solution for contacting peers (Has links to social media).

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(a)Monash 1 ^(b)Monash 2

(c)Monash 3 ^(d)Monash 3

Figure 2.8:Screenshots from the app FODMAP by Monash

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FODMAP helper

FODMAP helper by Appstronaut Studios has 50 000+ downloads on Google play store and has features such as FODMAP overview, log, log analysis, share food experience with the community (Analyzed foods) and FODMAP reintroduction. Screenshots from the app are displayed in figure 2.9 on the next page.

Pros:

• Conducts log analysis.

• Can share experience with the community concerning analyzed foods.

• Has FODMAP reintroduction stage.

Cons:

• Has no functionality for contacting peers.

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(a)FODMAP helper 1 (b)FODMAP helper 2

(c)FODMAP helper 3 ^(d)FODMAP helper 4

Figure 2.9:Screenshots from the app FODMAP helper

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Low FODMAP diet A-Z Food list for IBS sufferers

The app Low FODMAP diet A-Z Food list for IBS sufferers has 50 000+ google play store downloads and contains a FODMAP overview and added personalization. Screenshots from the app are presented in figure 2.10 on the facing page.

Pros:

• Personalization.

Cons:

• Has no log.

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(a)Low FODMAP diet A-Z 1 ^(b)Low FODMAP diet A-Z 2

(c)Low FODMAP diet A-Z 3

Figure 2.10:Screenshots from the app Low FODMAP diet A-Z Food list for IBS sufferers

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My Food Intolerance List

My Food Intolerance List by cr3ative.info, Steffen Mauser offers a FODMAP overview, personalization, and the ability to add tested ingredients to a private list. The app has 100 000+ downloads on Google play store. Screenshots from the app are presented in figure 2.11 on the next page.

Pros:

• Personalization.

Cons:

• Has no log.

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(a)My Food Intolerance List 1 (b)My Food Intolerance List 2

(c)My Food Intolerance List 3 ^(d)My Food Intolerance List 4 Figure 2.11:Screenshots from the app My Food Intolerance List

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Mr symptoms Food Diary and Symptom Tracker

Mr symptoms Food Diary and Symptom Tracker by SkyGazer Labs Ltd has over 100 000 downloads on the Google play store and sets the standard for log and log analysis. Screenshots from the app are displayed in figure 2.12 on the facing page.

Pros:

• Has advanced log and log analysis.

Cons:

• Is a pure logging app and is missing needed features.

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(a)Mr symptoms 1 ^(b)Mr symptoms 2

(c)Mr symptoms 3 ^(d)Mr symptoms 4

Figure 2.12:Screenshots from the app Mr symptoms Food Diary Symptom Tracker

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2.3.3 Review summary

Although papers are describing and presenting prototypes of apps and there are apps on the market for people with bowel dysfunctions and food allergies, they are not available and/or in widespread use in Norway and provide only parts of the complete functionality needed to address the target groups challenges.

What has become apparent through the systematic review is the need for complex and comprehensive logging as well as a direct connection with a health provider for people with inflammatory bowel diseased such as Chrons or Ulcerative Colitis.

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3

Method

The purpose of the project is to research, design, and develop a mobile app for people with intolerances, bowel dysfunctions, or allergies. The app should simplify the every-day life of the users through simplifying the food intake, logging, and communication between people with these challenges. To fulfill the purpose of the project, the methods described in this chapter has been used.

3.1 Setting

3.1.1 User scenarios

The user scenario method gives valuable insight into which groups of people can have use of the application through practical examples. Creating examples of use clarifies what functionality and requirements are needed for the application to fill the users’ needs. User scenarios for the project can be found in section 4.1.

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3.2 Participants

The app developed from this project is primarily intended to be used by people with digestive dysfunctions such as IBS, intolerance’s and/or food allergies.

People who follow complex medical diets will find the app most useful. Although people with inflammatory bowel diseases such as Chron’s or Ulcerative Colitis will have use of the app if they follow specific diets, they have more needs in terms of direct contact with health care providers and more complex logging as covered in multiple studies [10], [17]. Anyone shopping/cooking/planning meals for individuals with these challenges will also have use of the app for greatly simplifying the process of checking whether a meal is within the persons’

diet. Individuals with allergies will primarily have use of the scanning feature for identifying trigger foods and the barcode scanner.

3.3 Procedure

3.3.1 State of the art review

Reviewing state of the art is necessary when doing projects which should contribute to the market, field of study, or society as a whole. When creating mobile apps, it’s necessary to look into relevant apps in the market, as well as apps described in scientific papers. The review builds a base on which the project should be built on top of. The conducted reviews apps features, lack of features, and their design and usability were mapped and used to create a design for an app filling the needs in the market.

3.3.2 Pilot test

Once the app was mostly ready for a user test, the app was given out for testing by colleagues. They discovered inconsistencies in language, minor bugs and gave some general quality of life suggestions. Their suggestions were taken into consideration and implemented before the app was distributed for a user test.

3.3.3 User test

Landsforeningen mot fordøyelsessykdommer (LMF) were contacted at an early stage explaining the project and requesting aid in communicating with the user group. At an early stage, LMF posted a Facebook post explaining the project and the features of the app (displayed in figure 3.1 on page 36). In the

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post, the date for a user test was specified, and an expectation of answering an in-app questionnaire was expressed. Ca.100 people expressed an interest in testing the app through the Facebook post or e-mail. When the app was ready for the test, and the specified date came, the app was uploaded to Dropbox for download by the test group. Ca 10% of the test group downloaded and installed the app (based on accounts registered in the app). It was clear that sideloading an app through a Dropbox download was too complicated/too much effort for the majority of the test group. The app was therefore uploaded to Google play store in an open beta test (figure 3.3 on page 38). This allowed users to install the app just like any other Google play store app, considerably lowering the complexity and effort to install the app. Simpler install combined with a new Facebook post from LMF informing about the availability of the app (figure 3.2 on page 37), caused the number of installs to increased significantly to the point of 65 users (not including co-students, friends, and family). For the app to be uploadable to the Google play store, the app needed a home page, as displayed in figure 3.4 on page 39.

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Figure 3.1:LMF first post

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Figure 3.2:LMF second post

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Figure 3.3:Google play store

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Figure 3.4:Home page

The app contained a survey answerable from within the app. The survey is a service provided by the University of Oslo 1 presented in the app through an in-app browser. The survey consisted of the system usability scale in addition to a few app-specific questions. User feedback was also collected from the in-app forum where the users gave requests for features and tweaks during the test phase.

Some feedback on the project itself was given on the Facebook post presenting the project:

Woman: "I would like to try the app when it’s published. I have Chron’s, but my doctor also thinks I have IBS. Would like to try the low-FODMAP diet, but I think it’s a little complicated and a lot of work, so if an app is made available which simplifies the process it would have been great. I’m rooting for the project. Good luck!"

Woman: "Would like to test the app. Tired of laying in the fetus position in the bathroom x times a week..."

1.https://nettskjema.no/

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Woman: "Would like to test the app. I have active Chron’s, and no medication has worked so far."

Woman: "Would like to test. I’ve had IBS for 17 years. I am following the low FODMAP diet, which works well for me."

Woman: "I would like to test the app. I have Chron’s and have no effect from medications. I am currently using low FODMAP and stress relief as a treatment.

Would like an app to keep me on track with the diet.

Woman: "I would like to test the app! I’ve had IBS for over 20 years."

The feedback received shows a clear need for the app in the market and for the target group.

3.4 Analysis of ﬁndings

The questionnaire distributed to the test participants contained the system usability scale, which is a standard for usability, as well as some application- specific questions. In addition to the questionnaire, feedback on the project itself and the application was received over Facebook and the in-app forum. The additional feedback was handled without the use of any specific tools.

3.4.1 System usability scale

The system usability score of the application was calculated as follows. Each SUS question has a contribution score from 0-4. For questions 1,3,5,7 and 9, its contribution score is the scale position minus 1. For questions 2,3,6,8 and 10, the contribution score is 5 minus the scale position. The sum of the scores is multiplied by 2.5 to obtain the total system usability score [1]. The Norwegian version of the SUS was created by the author and has as such not been validated for correctness or accuracy compared to the original English version, and may as such not be accurate [18]. The SUS score of the implemented application is presented in section 7.7.

3.5 Criticism of methods

Due to time constraints, some areas have room for improvement. The systematic review and the app review could have been more thorough. There is a

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vast number of apps which might be relevant to some degree for the project, but testing all of them is a time-consuming process. Therefore only the top apps have been tested. The user-test phase of the project could have been extended or ran in multiple iterations. If after each test, the app was improved based on feedback, the resulting app would better suit the needs of the target group.

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4

Requirement speciﬁcation

The requirements for the app was based on the conducted app review of com- peting apps available in the Norwegian market combined with the conducted systematic review of relevant papers, as well as personal experience dealing with intolerances. Individuals with bowel disorders and intolerances have also played a role in setting the requirements for the app. An individual with IBS and following the low-FODMAP diet wanted a simple overview and control system for checking FODMAPs in ingredients and products.

4.1 User scenarios

Let’s take a look at a couple of use cases for the application. The apps primary target is persons with digestive dysfunctions such as IBS. An example scenario for this group is displayed in figure 4.1 on the next page. In the morning the person wakes up and does an overall evaluation of his shape, and logs any symptoms, bowel movement, and sleep. The user eats breakfast and logs the meal. After an hour, the app prompts the user for logging of symptoms. If the user has any, he logs them. At lunch, it’s the same procedure. When the time is right for shopping groceries, he writes a list of what groceries are needed. If he has any recipes he wants to use, he scans the recipe for trigger food and modifies the recipe if needed. He takes the app with him to the store, looks up any unfamiliar products with the barcode scanner, takes a picture of the ingredient declaration, or searches the food in question manually. Once the

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food has been made, and he’s eaten, he logs the meal. Once again, he logs any symptoms after an hour. In the evening, he browses the apps forum for tips and tricks and asks questions about IBS.

Log bowel movement and health.

8:00 - Breakfast Log: Meal

12:00 - Lunch Log: Meal.

9:00

Push:

Symptoms breakfast.

Push:

General shape.

13:00

Push:

Symptoms lunch.

16:00 Shopping groceries.

Uses barcode scanner + ingredient database in combination with log-data..

17:00 - Dinner Log: Meal.

18:00

Push:

Symptoms dinner.

19:00 - Exercise Log: Exercise

20:00 Forum: Discuss the challenges

of the day.

21:00 - Supper Log: Meal.

22:00

Push:

symptoms supper.

Figure 4.1:Time line of example of use

For friends, family, and anyone cooking or shopping groceries for a person with intolerances, the app has a more limited use than for the primary target group.

An example would be a family member planning a dinner for a person following the low-FODMAP diet. The family member writes a shopping list of ingredients needed for a meal and scans the list with the app. The app gives feedback on which ingredients are within or outside the diet. He or she then proceeds with finding alternatives for the ingredients which are not low-FODMAP and repeats the scanning, alternatively checks the ingredient in question manually, until all ingredients are okay. If he/she plans on using any products from the store, he/she use the barcode scanner while shopping to figure out which product (if any) are okay.

For a caterer, the app can be used when developing a menu with courses within a specific medical diet or intolerance. The process is the same as the previous scenario where the list of ingredients for a menu item is scanned when creating the menu, refining the list until no trigger foods are present.

4.2 Requirements

Using the Volere requirement specification [19], the following table was created. The table has the following abbreviations: type 1: Product purpose, 5:

Naming conventions and definition, 8: Product scope, 9: Functional and data requirement, 11: Usability requirement. Customer satisfaction and customer dissatisfaction are in the rightmost columns.

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Requirements

Req

# Type

*

Description Rationale Source Fit Criterion S

a t

* D i s s a t

* 1 1 Simplify following a

medical diet

Following complex medical diets is difficult and time consuming

Author The process of following a complex medical diet shall be simpler with the app than

without

5 3

2 5 Shall use norwegian language and products

There are no apps with the needed functionality for the

norwegian market

Author The apps language and products shall be all norwegian

5 3

3 8 Shall use a norwegian food product database

The app shall be suitable for norwegian users

Author The app has info from a norwegian food product database

5 3

4 9 Food analyzed for FODMAPs/ intolerances

shall be searchable by text

Core feature which simplifies following a diet

Author The food shown to the user shall be the food searched for

3 4

5 11 The app shall be able to scan images for trigger

foods

Significantly simplifies following complex diets and lowers the

effort needed to use the app

Author When scanning images of ingredients the app shall produce a result with information on

the ingredients and their matching intolerances if it's in the database

5 2

6 9 Looking up products available in norwegian

grocery stores shall return relevant FODMAP, intolerance,

allergy and nutritional information

Allowing products to be looked up is easier than searching each

ingredient

Author When looking up products it shall display relevant FODMAP, intolerance, allergy and

nutritional information

3 2

7 11 Products shall be able to be looked up through

barcode scanning

Scanning the barcode is simpler than searching for a product

Author When utilizing the app a barcode scan option shall be available, and the result from the

scan shall give relevant FODMAP, intolerance, allergy and nutritional information on the product if it exist in the

database

5 2

8 11 Users shall be able to add products to the

product database

Having an expandable database includes the users in the app and increases the chance of

finding products

Author There shall be a option for the user to add products to the database. The product added

shall be searchable by other users

2 1

9 11 Adding products for users shall be simple

Motivates adding products Author The process of adding products shall be seen as simple and not time consuming from

the users perspective

2 1

10 11 Products added by users shall instantly and

automatically be classified for intolerances

Giving the users the ability to instantly receive product information motivates adding products and provides the users

with information when needed

Author Instantly after adding a product the product shall be searchable and provide information

3 1

;

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analyzed for FODMAPs gives symptoms 12 9 The app shall contain a

log system for logging food intake, symptoms, stress, exercise, bowel movements and other

relevant factors

Essential feature for keeping track of intake and events and

their resulting symptoms

Author The app shall contain a log system for logging food intake, symptoms, stress, exercise, bowel movements and other relevant factors. The events logged shall be

the events displayed in the log

3 2

13 11 The logging interface shall be simple

Simple interfaces makes it less of an effort to utilize the log

Target group

The users shall not consider the logging as too time consumable

3 2

14 11 The app shall remind the user to utilize the log

Makes logging more likely, and improves accuracy compared to

logging once a day

Author The app shall be able to present users with push notifications

1 1

15 11 The log shall be complex enough to gather needed

information

Provides the user with important information

Target group

The app shall allow the user to input information covering the events and

symptoms

3 3

16 11 The log shall provide analysis for which events

trigger which symptoms

Provides simple and clear information on which food and

events gives which symptoms

Author Analysis of the log concerning which events cause which symptoms shall be conducted

and presented to the user in a understandable fashion

4 2

17 11 The user shall be able to personalize the app to fit

their intolerances

Makes the app suitable for more people, and makes the app feel

more tailored

Author Which trigger foods searched for and searchable in the app shall be changed

based on the users customization

3 2

18 9 The app shall provide a communication platform for users to communicate

with each other

Lets the users feel part of a community, and allows users to

reach and help each other

Author A user shall be able to read/write posts in the platform and thereby reach other users

2 1

;

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Let’s discuss some of the requirements.

4.2.1 Requirement 4-5

Having the ability to search for foods analyzed for FODMAPs/known trigger foods for the intolerance in question, is the core and often only feature of many FODMAP apps. Half of the apps in the app review has this feature. This strongly supports the importance of such a feature. While having a searchable overview is fine, being able to scan images for trigger foods greatly simplifies the process and differentiates the app from most others on the market.

Although checking a single ingredient or many at a time for trigger foods through scanning images provides possibilities to check all ingredients in a product, being able to scan only a barcode and get the same information in addition to nutritional information makes the app more user-friendly.

For discovering relations between consumption, events, and symptoms logging is the most effective tool. Apps such as FODMAP by Monash, FODMAP helper, and Belly Balance supports this feature’s importance in FODMAP applications, while apps such as Mr. Symptoms Food Diary and Symptom Tracker sets a standard for design and interface. The benefits of utilizing mobile devices to log at sporadic or strategical intervals during the day instead of using the recall method is supported by the findings of Z. Mujagic et al. [6].

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5

Design

5.1 Color scheme

The color scheme for the app has, as displayed in figure 5.1 on the following page, changed from black and grey tones to shades of orange and purple with blue menu and buttons. While grey represents the feeling of uncertainty, the new color scheme is connected with warmth, calm and happier emotions [20], which is beneficial for the target group since the target group has a higher chance of having anxiety and depression.

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(a)Old scheme (b)Current scheme Figure 5.1:Old vs new color scheme

5.2 Ease of use

The application is created with ease of use in mind. Minimizing the number of clicks needed for each operation increase the likelihood of regular use.

5.3 Users

When it comes to users in a system containing sensitive information, it is important to create and store users in such a way that no security or privacy violations are encountered. Most applications store email and password, but email can often easily identify the user. Using username only can reduce the possibility of identification drastically. The username can also lead to identification, but only if the user creates an identifiable user name. Once the user is logged in, he remains logged in as long as his user token has not expired, in which case he must log in again.

DiDiMap. Diet Diary and Consumption Control for Monitoring Bowel Dysfunctions and low-FODMAP Diet App

Abstract

Preface

Contents

List of Figures

List of Tables

1

Introduction

1.1 Motivation

1.2 Problem statement

1.3 Nature and scope of problem

1.4 Method

1.5 Signiﬁcance and contributions

1.6 Organization

2

Theoretical framework

2.1 Medical background

2.2 Technical background

2.3 State of the art

3

Method

3.1 Setting

3.2 Participants

3.3 Procedure

3.4 Analysis of ﬁndings

3.5 Criticism of methods

4

Requirement speciﬁcation

4.1 User scenarios

4.2 Requirements

Requirements

5

Design

5.1 Color scheme

5.2 Ease of use

5.3 Users